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SEVERE HYPERTENSION
• BP >180/110 mmHg
• Categories of severe hypertension
– Asymptomatic
– hypertensive urgencies
hypertensive
– hypertensive emergenciescrises
Asymptomatic severe
hypertension
• Admission may be necessary (new
case or poor compliance)
• If patient already on treatment –
review drug regime
Hypertensive urgencies
• Grade III or IV retinal changes & no
overt organ failure.
• Also known as accelerated (III) and
malignant (IV) hypertension
Cotton wool spots and Optic disk
flame shape swelling
hemorrhage
Managements of Hypertensive
•
urgencies
Patients may need admission
• Repeat BP after 30 min bed rest
• Drugs of choice;
Drug Dose Onset Duratio Freque
of n (hr) ncy
Captopr 25 mg action
0.5 6 (prn)
1–2
il (hr) hrs
Nifedipi 10 – 20 0.5 3–5 1–2
ne
Labetal mg
200 – 2.0 6 hrs
4 hrs
ol 400 mg
Sodium
nitroprussid 0.25 – 10 μg/kg/min seconds 1 – 5 min Caution in renal failure
e
IV bolus (over at least
1 minute) repeating if necessary
Labetalol ≤ 5 min 3 - 6 hrs Caution in heart failure
at 5 minute intervals to a max of
200 mg then 2 mg/min IVI
Preferred in acute coronary
Nitrates 5 – 100 μg /min 2 – 5 min 3 – 5 min syndromes and acute
pulmonary Oedema
IV 5–10 mg
Caution in acute coronary
maybe repeated after 20 - 30
10 – 20 min syndromes, cerebrovascular
Hydralazine minutes IVI 200-300 mcg/min 3 – 8 hrs
20 – 30 min accidents and dissecting
initially.
aneurysm
Maintenance 50-150 mcg /min
Caution in acute heart
IV bolus 10-30 mcg/kg over 1
Nicardipine 5 – 10 min 1 – 4 hrs failure and coronary
minute IVI 2–10 mcg/kg/min
ischaemia
IV bolus1 – 2 min
Used in peri-operative
250–500 mcg/kg over 1 min
Esmolol 3 – 10 min situations and
IVI 50–200 mcg/kg/min for 4 min.
tachyarrhythmias
May repeat sequence
HYPERTENSION IN
SPECIAL GROUPS
HYPERTENSION IN SPECIAL
GROUPS
1) Hypertension and Diabetes Mellitus
2) Hypertension and the Metabolic Syndrome
3) Hypertension and Non-Diabetic Renal
Disease
4) Renovascular Hypertension
5) Hypertension and Cardiovascular Disease
6) Hypertension and Stroke
7) Hypertension in the Elderly
8) Hypertension and Oral Contraceptives
9) Hypertension and Hormone Replacement
Therapy
10)Hypertension in Children and Adolescents
Hypertension and Diabetes
Mellitus
• Incidence;
– type 1 diabetes, the incidence of
hypertension increases from
• 5% at 10 years
• 33% at 20 years and
• 70% at 40 years.
IDF 2005
COMPULS
Waist
ORY ≥ <1.0 (M)
criterion + ≥ 5.6 ≥ 1. 7
>90 (M) 130/85 <1.3 (F)
2 out of 4
>80 (F)
criteria
HPT & MS
• HPT with MS should be treated
according to standard clinical
practice guidelines.
• Beta-blockers and thiazide
diuretics have the potential to
increase the incidence of new onset
diabetes
(this should be taken into
consideration when choosing drugs
for patients diagnosed with the
Hypertension and Non-Diabetic
Renal Disease
• Renal disease can be a cause or
complication of HPT
• HPT with renal disease often
associated with ↑ serum creatinine,
proteinuria and/or haematuria.
• The target BP
o < 130/80 mmHg for proteinuria of <
1g/24 hours
o < 125/75 mmHg for proteinuria of >
1g/24 hours
Hypertension and Non-
Diabetic Renal Disease
• Managements - Control BP and proteinuria
• Drugs of choice; ACEI & ARBs – has effective
anti-proteinuric effect.
Must check serum creatinine within the first two weeks of
initiation of therapy. If persistently high (> 30% from
baseline) more than 2 months, stop the ACEI or ARBs.
thank you...
• Proceed with real case
discussion...
Case scenario
Puan A, 57 year-old housewife, a known
case of essential hypertension and
ischemic heart disease came to clinic
for medication review.
The hypertension was diagnosed 27
years ago and she then was started
with antihypertensive medications.
She has history of ischemic heart disease,
diagnosed 4 years ago when she had
chest pain. She was admitted at S.H. for
4 days and discharged well.
Cont.
She claims the blood pressure is
remain low till now and has no
episodes of IHD after the discharge.
She is not diabetic or having other
diseases.
She has no family history of chronic
disease and she is non-smoker.
Cont.
Examination
– BMI; 32
– Blood Pressure; 148/86 mmHg
– CVS; 1st&2nd heart sound heard, DRNM
– Respiratory; Lung is clear
How Do You Manage This
Patient?
Drugs of Choice
• Antihypertensive
– Beta1 receptor blocker; Metoprolol 50
mg bd
– CCB; Amlodipine 20 mg od
• Other medications (1)
1) C l i n i c a l P r a c t i c e G u i d e l i n e s o n U A / N ST EMI 2 0 0 2
Others
• Lifestyle modification
• Investigation ordered; fasting blood
glucose, fasting lipid profile, renal
profile, ECG, LFT
• TCA in 2 weeks
that all, thank you for your
kind attention